8. St Austell Healthcare

8. St Austell Healthcare

Overview

St Austell has high levels of long-term unemployment and socio-economic deprivation as well as a high prevalence of chronic disease and obesity. The primary care home model offered a framework for one large practice to redesign services and offer new ones in partnership with a wide range of statutory and voluntary sector organisations. Its vision is to provide sustainable services to its patients, meeting unmet needs and enabling people to access non-clinical solutions.

How things are changing

The primary care home has established integrated, multidisciplinary teams and opened up access to many non-clinical activities which can address the wider determinants of health. It has focussed on three key workstreams: social prescribing, integration of health and social care and workforce development. The results are better and new services, less duplication and more skills development for staff and closer, cross-sector links with people in the local community through various methods including a launch event facilitated by the NAPC.

Many of the practice’s patients are frail older people who are physically inactive, often socially isolated and lonely. Poverty and unemployment are also major challenges. The practice engaged with community providers, employing a social prescribing facilitator who sees patients and refers them to bespoke resources ranging from walking groups to Zumba, pilates classes and a canoe club, to increase their physical activity, improve their diet and reduce isolation. More than 350 patients have joined the scheme – 94% have shown an increase in their wellbeing score and 62% have lost weight. After six months, there was a 50% drop in the number of appointments made by patients taking part in the scheme, representing more than 500 appointments saved.

An integration manager role has been created to improve hospital discharges, the treatment of complex patients and palliative care. Home visits are being managed better and duplication has been reduced. GPs had been making 30 home visits a day but many patients were also being visited by district nurses, community matrons and the mental health team. Community nurses and district nurses have also been co-located at the practice’s acute hub which sees urgent same-day cases.

An integration manager role has been created to improve hospital discharges, the treatment of complex patients and palliative care. Home visits are being managed better and duplication has been reduced. GPs had been making 30 home visits a day but many patients were also being visited by district nurses, community matrons and the mental health team. Community nurses and district nurses have also been colocated at the practice’s acute hub which sees urgent same-day cases. Feedback from community teams has been excellent and they have begun to fill previously vacant posts. The PCH has concentrated on skills development for staff and diversifying the team. Two pharmacists are part of the practice team carrying out medication reviews. There is a nurse-led minor illness team, with the team internally trained and an acute visiting service using emergency care practitioners.

Prescribing costs and secondary care referral rates have reduced since the establishment of the primary care home. Staff are optimistic about the future and clinicians across the multidisciplinary team are being recruited as the PCH prepares to play an active role in the development of a new accountable care organisation in Cornwall. St Austell has high levels of long-term unemployment and socio-economic deprivation as well as a high prevalence of chronic disease and obesity. The primary care home model offered a framework for one large practice to redesign services and offer new ones in partnership with a wide range of statutory and voluntary sector organisations. Its vision is to provide sustainable services to its patients, meeting unmet needs and enabling people to access non-clinical solutions.

Lessons learnt: It takes time to build the relationships between organisations needed to make this work. Time to lead is essential.

The National Association of Primary Care (NAPC) is a leading membership organisation representing the interests of primary care professionals including general practitioners, nurses, practice staff, pharmacists, opticians and dentists.